Treatment of consecutive episodes of major depression in the elderly

Failure to Respond after Reinstatement of Antidepressant Medication: A Systematic Review

BACKGROUND

Following remission of an anxiety disorder or a depressive disorder, antidepressants are frequently discontinued and in the case of symptom occurrence reinstated. Reinstatement of antidepressants seems less effective in some patients, but an overview is lacking. This systematic review aimed to provide insight into the magnitude and risk factors of response failure after reinstatement of antidepressants in patients with anxiety disorders, depressive disorders, obsessive-compulsive disorder (OCD), or posttraumatic stress disorder (PTSD).

METHOD

PubMed, Embase, and trial registers were systematically searched for studies in which patients: (1) had an anxiety disorder, a depressive disorder, OCD, or PTSD and (2) experienced failure to respond after reinstatement of a previously effective antidepressant.

RESULTS

Ten studies reported failure to respond following antidepressant reinstatement. The phenomenon was observed in 16.5% of patients with a depressive disorder, OCD, and social phobia and occurred in all common classes of antidepressants. The range of response failure was broad, varying between 3.8 and 42.9% across studies. No risk factors for failure to respond were investigated. The overall study quality was limited.

CONCLUSION

Research investigating response failure is scarce and the study quality limited. Response failure occurred in a substantial minority of patients. Contributors to the relevance of this phenomenon are the prevalence of the investigated disorders, the number of patients being treated with antidepressants, and the occurrence of response failure for all common classes of antidepressants. This systematic review highlights the need for studies systematically investigating this phenomenon and associated risk factors.

Depressed older adults may be less cared for than depressed younger ones

The aim of the study was to investigate depression treatment use, either psychotherapy (PT) or antidepressant drugs (ADT) in the older and younger depressed population. Cohorts of 6316 elderly (≥65 year-old) and 25,264 matched non-elderly (25-64 year-old) depressed patients were created from a large national claims database of managed care plans from 2003 to 2006. Factors associated with ADT or PT were assessed using multivariate logistic models. During the 120 days following the depression diagnosis, the elderly persons were less often treated than the younger adults either by ADT (25.6% vs. 33.8%) or by PT (13.0% vs. 34.4%). ADT dispensing occurred later in the elderly group (51 vs. 14 days). ADT was associated with comorbid chronic conditions or polypharmacy in the elderly and younger adults. The selection of treatment (ADT or PT) was associated with the history of treated depression using the same type of treatment, in both groups. Thus, depression goes commonly untreated. Comorbidity was associated with higher ADT dispensing rates. However, although depressed elderly commonly presented with comorbidity, this age group was at higher risk of untreated illness or later treatment.

Trends in antidepressant use in the older population: results from the LASA-study over a period of 10 years

BACKGROUND

In the past 15 years, antidepressant use in adults has increased, mainly due to a rise in SSRI-use. The question is if this is true for older adults as well.

METHODS

Data from the Longitudinal Aging Study Amsterdam were used to investigate trends in antidepressant use from 1992 through 2002 in a population-based sample aged 65-85 years.

RESULTS

Antidepressant use increased from 2% to 6%. In the group with major depressive disorder, treatment with antidepressants showed an increase from 15% to 30%. This increase was larger in the older-old than in the younger old. Also, the increase was mainly due to a rise in SSRI-use. Daily TCA-dosages often were too low; dosages of the other antidepressants seemed to be sufficient. However, rates of depression remained stable, in the treated as well as in the untreated group.

LIMITATIONS

Non-response was associated with depression, the indication for prescription of antidepressants was not known, and serum concentrations of antidepressants were not available.

CONCLUSIONS

Antidepressant use in older people increased over the past 15 years, mainly due to a rise in SSRI-use. Daily dosages of antidepressants had become more adequate. Still only a minority of the more severely depressed used antidepressants.

Psychotherapeutic treatments for older depressed people

BACKGROUND

Despite a number of reviews advocating psychotherapy for the treatment of depression, there is relatively little evidence based on randomised controlled trials that specifically examines its efficacy in older people.

OBJECTIVES

To examine the efficacy of psychotherapeutic treatments for depression in older people.

SEARCH STRATEGY

CCDANCTR-Studies and CCDANCTR-References were searched on 11/9/2006. The International Journal of Geriatric Psychiatry and Irish Journal of Psychiatry were handsearched. Reference lists of previous published systematic reviews, included/excluded trial articles and bibliographies were scrutinised. Experts in the field were contacted..

SELECTION CRITERIA

All randomised controlled trials that included older adults diagnosed as suffering from depression (ICD or DSM criteria) were included. All types of psychotherapeutic treatments were included, categorised into cognitive behavioural therapies (CBT), psychodynamic therapy, interpersonal therapy and supportive therapies.

DATA COLLECTION AND ANALYSIS

Meta-analysis was performed, using odds ratios for dichotomous outcomes and weighted mean differences (WMD) for continuous outcomes, with 95% confidence intervals. Primary outcomes were a reduction in severity of depression, usually measured by clinician rated rating scales. Secondary outcomes, including dropout and life satisfaction, were also analysed.

MAIN RESULTS

The search identified nine trials of cognitive behavioural and psychodynamic therapy approaches, together with a small group of 'active control' interventions. No trials relating to other psychotherapeutic approaches and techniques were found. A total of seven trials provided sufficient data for inclusion in the comparison between CBT and controls. No trials compared psychodynamic psychotherapy with controls. Based on five trials (153 participants), cognitive behavioural therapy was more effective than waiting list controls (WMD -9.85, 95% CI -11.97 to -7.73). Only three small trials compared psychodynamic therapy with CBT, with no significant difference in treatment effect indicated between the two types of psychotherapeutic treatment. Based on three trials with usable data, CBT was superior to active control interventions when using the Hamilton Depression Rating Scale (WMD -5.69, 95% CI -11.04 to -0.35), but equivalent when using the Geriatric Depression Scale (WMD -2.00, 95% CI -5.31 to 1.32).

AUTHORS' CONCLUSIONS

Only a small number of studies and patients were included in the meta-analysis. If taken on their own merit, the findings do not provide strong support for psychotherapeutic treatments in the management of depression in older people. However, the findings do reflect those of a larger meta-analysis that included patients with broader age ranges, suggesting that CBT may be of potential benefit.

Relationship between the Hamilton Depression Rating Scale and the Montgomery-Asberg Depression Rating Scale in depressed elderly: a meta-analysis

OBJECTIVE

To determine whether the sensitivity of the Hamilton Depression Rating Scale (HDRS) and Montgomery-Asberg Depression Rating Scale (MADRS) to treatment effects are comparable in geriatric antidepressant randomized controlled trials by developing and validating an equation that links between the two instruments.

METHODS

Literature search for this meta-analysis was based on three sources: MEDLINE, a recent related meta-analysis, and experts in geriatric antidepressant trials. The search resulted in 11 relevant geriatric antidepressant trial studies that administered both instruments for symptom ratings. The authors used baseline ratings as a model-building sample and postrandomization ratings as a validation sample. HDRS scores were prorated into HDRS17, a 17-item HDRS, for analysis. The development and validation was based on a total number of 1,874 subjects.

RESULTS

The correlations were high between baseline mean HDRS17 and MADRS ratings (r = 0.80; Fisher's z = 1.09, N = 25, p <0.0001) and between postrandomization ratings (r = 0.88, Fisher's z = 1.39, N = 65, p <0.0001). The following equation was derived: HDRS17 = -1.58 + 0.86 x MADRS. The difference between observed and estimated HDRS17 in a validation sample consisting of postrandomization follow-up means did not depend on magnitudes of HDRS17.

CONCLUSION

Although generalizability of findings into a broader population could be limited, and the authors could not assess concordance of changes of particular item constructs between HDRS and MADRS ratings, both ratings are comparable in assessing changes in overall depressive symptom severity in response to antidepressants in depressed elderly at aggregated group mean levels.

Effect of comorbid anxiety on treatment response and relapse risk in late-life depression: controlled study

BACKGROUND

Comorbid anxiety is common in depressive disorders in both middle and late life, and it affects response to antidepressant treatment.

AIMS

To examine whether anxiety symptoms predict acute and maintenance (2 years) treatment response in late-life depression.

METHOD

Data were drawn from a randomised double-blind study of pharmacotherapy and interpersonal psychotherapy for patients age 70 years and over with major depression. Anxiety symptoms were measured using the Brief Symptom Inventory. Survival analysis tested the effect of pre-treatment anxiety on response and recurrence.

RESULTS

Patients with greater pretreatment anxiety took longer to respond to treatment and had higher rates of recurrence. Actuarial recurrence rates were 29% (pharmacotherapy, lower anxiety), 58% (pharmacotherapy, higher anxiety), 54% (placebo, lower anxiety) and 81% (placebo, higher anxiety).

CONCLUSIONS

Improved identification and management of anxiety in late-life depression are needed to achieve response and stabilise recovery.

Drug treatment in depressed elderly in the Dutch community

OBJECTIVES

In older people, a diagnosis of depression is frequently missed, and proper treatment is subsequently hampered. We investigated antidepressant and benzodiazepine use in an older community sample, and assessed possible risk factors associated with non-treatment in depressed elderly.

METHODS

Data were used from the baseline measurements of the Longitudinal Aging Study Amsterdam (LASA). In a random, age and sex stratified community sample of 3107 older Dutch people (55 to 85 years), respondents were screened on depression with the Center for Epidemiologic Studies Depression Scale (CES-D). In the depressed subsample depressive disorder according to DSM-III was assessed using the Diagnostic Interview Schedule (DIS). The use of antidepressants and anxiolytics (benzodiazepines) in the depressed subsample was measured, and associations with age, sex, cognitive impairment, physical health and anxiety symptoms were investigated.

RESULTS

Only 16% of the respondents with a major depressive disorder used antidepressants. More than half of them used non-therapeutic dosages. Lower antidepressant use was associated with cognitive impairment. Benzodiazepine use was more likely than antidepressant use, which was especially evident in females in the major depressive disorder group.

CONCLUSIONS

Depressed older people were undertreated, particularly when they were cognitively impaired. A high rate of benzodiazepine use was found, particularly in females.

Psychotherapy and combined psychotherapy/pharmacotherapy for late life depression

Over the past 20 years, numerous studies have investigated the efficacy of psychotherapy for treating late life depression and, to a lesser degree, the efficacy of psychotherapy combined with antidepressant medication. Of the intervention studies, cognitive-behavioral therapy and interpersonal psychotherapy combined with antidepressant medication have the largest base of evidence in support of their efficacy for late life depression. To a lesser degree, there is support for stand-alone interpersonal psychotherapy, brief dynamic therapy, and life review treatments. The purpose of this review is to present data on the acute and long-term effects of cognitive-behavioral therapy, interpersonal psychotherapy, brief dynamic therapy, and combined antidepressant medication and psychotherapy to discuss the generalizability of these interventions, and to discuss future research directions and the need for increased opportunities for this area of research.

Chronic depression in the elderly: approaches for prevention

Depression in old age frequently follows a chronic and/or relapsing course, related to medical comorbidity, cognitive impairment and depletion of psychosocial resources. As endorsed by the US National Institutes of Health (NIH) Consensus Development Conference on the Diagnosis and Treatment of Late Life Depression, a major goal of treatment is to prevent relapse, recurrence and chronicity. We believe that most, if not all, elderly patients with major depressive episodes are appropriate candidates for maintenance therapy, because of the vulnerability to relapse and recurrence and because of the favourable benefit to risk ratio of available treatments. Antidepressant pharmacotherapy is the mainstay of this therapeutic goal, but psychosocial approaches (especially interpersonal psychotherapy) have also been shown to contribute significantly to prevention of a chronic depressive illness and to prevention of the disability that attends depression. Studies published to date have established the long term or maintenance efficacy of the tricyclic antidepressant nortriptyline. Current, ongoing studies are addressing the maintenance efficacy of paroxetine and citalopram to prolong recovery in depression associated with old age. These studies are focusing particularly on patients aged 70 years and above, who are at high risk of recurrence, and on patients in primary care settings, where under-recognition and under-treatment of depression in the elderly have been costly from a public health perspective in terms of increased medical utilisation, burden to patients and families, and high rates of suicide. Depression in old age is a major contributor to the global burden of illness-related disability, but it is extremely treatable if appropriate pharmacotherapy is prescribed and accepted by patients and their caregivers.

Treatment of depression in late life: psychotherapeutic interventions

Depression affects only a minority of older adults, but is a costly illness in terms of suffering, excess medical disability, increased use of health services, and mortality. Both pharmacological and psychotherapeutic interventions are effective for treating depression in late life. This paper reviews the background and empirical support for the efficacy of various psychotherapies for treating late life depression, including cognitive-behavioral, interpersonal, psychodynamic, life review, group, and family interventions. To date, cognitive-behavioral and interpersonal psychotherapies have most empirical support yet most studies have been conducted with relatively young, healthy, and White elderly. Studies of the efficacy of psychotherapeutic interventions for treating depression in minority and frail elderly are needed, as well as further studies of combination treatments across a range of care settings.

Psychosocial considerations in elderly patients with heart failure

Neuropsychiatric conditions, such as Alzheimer's dementia, and complications, such as delirium, are common in elderly patients with heart failure. Persistent alcohol abuse and cigarette smoking sometimes contribute to the onset and progression of heart failure. Major depression and other depressive disorders are common in this population and have adverse effects on functional status, quality of life, and prognosis. Anxiety and social isolation are clinically significant problems in many cases. These problems often are treatable and deserve more clinical attention than they typically receive.

Poor prognosis of depression in elderly people: causes and actions

Depression is the most common mental health problem of older people. It is a serious disorder which can lead to persistent suffering, increased mortality, from both suicide and general medical causes, and poorer overall health. Although presenting symptoms are similar in all age groups there are different aetiological pathways. In older people the waning effect of genetic predisposition to affective disorder may be replaced by subcortical brain abnormalities of presumed vascular aetiology. These may influence prognosis. Depression in later life is often under-diagnosed and under-treated; these two factors are the main hurdles to an improved prognosis. Antidepressant treatment should be tailored to the patient and works best when combined with psychological therapy, but the latter treatment modality is woefully neglected in later life psychiatry. Improvements in prognosis are unlikely to come from new revolutionary treatments but from vigorous treatment in the acute phase, continuation after recovery for at least 12-18 months and long-term maintenance treatment for those at high risk of recurrence.

Recovery from episodes during the course of affective disorder: a case-register study

OBJECTIVE

The aim of the study was to investigate whether the duration of treated episodes changes during the course of unipolar and bipolar affective disorder.

METHOD

The rate of recovery from successive hospitalized episodes was estimated with survival analyses in a case-register study including all hospital admissions with primary affective disorder in Denmark during the period 1971-1993.

RESULTS

A total of 9174 patients with recurrent episodes were followed from their first admission. The rate of recovery from hospitalized episodes did not change with the number of episodes in unipolar or bipolar disorder. Furthermore, the rate of recovery was constant across episodes, regardless of the combination of age, gender and type of disorder. Initially in the course of the illness, the rate was a little faster for bipolar than for unipolar patients, but later in the course of the illness the rate of recovery was the same for the two disorders.

CONCLUSION

It is concluded that, in modern treatment settings, the duration of affective episodes appears to be stable during the course of unipolar and bipolar disorder.

Long-term course and outcome of depression in later life

Depression in later life is usually a recurrent illness and often a chronic one, associated with increased health care utilization, amplification of the disability born of concurrent medical illness, decreased quality of life, increased risk for suicide, and cognitive impairment. The good news, however, is that maintenance treatments work and have a demonstrably positive impact on long-term illness course. Treatment response is especially variable, or brittle, in patients aged over 70; yet maintenance treatment with combined medication and psychotherapy is able to significantly reduce long-term treatment response variability, ensuring continued wellness. Further evaluation of cost-effectiveness is necessary in order to improve reimbursement for effective long-term treatment.

Maintenance nortriptyline effects on electroencephalographic sleep in elderly patients with recurrent major depression: double-blind, placebo- and plasma-level-controlled evaluation

Our aim was to contrast the effects of maintenance nortriptyline and placebo on electroencephalographic sleep measures in elderly recurrent depressives who survived 1-year without recurrence of depression. Patients on nortriptyline took longer to fall asleep and did not maintain sleep better than patients on placebo; however, maintenance nortriptyline was associated with more delta-wave production and higher delta-wave density in the first non-REM (NREM) period relative to the second. Nortriptyline levels were positively but weakly related to all-night delta-wave production during maintenance (accounting for 6.6% of the variance in delta-wave counts). Total phasic REM activity increased 100% under chronic nortriptyline relative to placebo, with a robust increase in the rate of REM activity generation across the night. Effective long-term pharmacotherapy of recurrent major depression is associated with enhancement in the rate of delta-wave production in the first NREM period (i.e., delta sleep ratio) and of REM activity throughout the night.

The effect of treatment on the two-year course of late-life depression

BACKGROUND

The purpose of this study was to examine the effect of treatment on the long-term course of geriatric depression.

METHOD

Eighty-four elderly patients who had responded to treatment of the index episode of major depression were maintained on full-dose antidepressant medication and followed on a monthly basis for two years. Relapse and recurrence were treated in a systematic manner.

RESULTS

The cumulative probability of surviving for two years without relapse or recurrence was 74%. Of the 14 patients who suffered recurrence following recovery from the index episode, all responded to a change of treatment, and 71% remained well for the remainder of the study. The risk of recurrence was significantly increased by a delayed response to treatment of the index episode.

CONCLUSIONS

Continuation and maintenance treatment with full-dose antidepressant medication, frequent follow-up, and vigorous treatment of relapses and recurrences, were associated with a good outcome in this group of elderly patients.

Treatment of major depression in later life: a life cycle perspective

The goal of this article is to provide a life-cycle perspective on the treatment of major depressive episodes in later life. Our studies have suggested that older patients appear to benefit as much, though perhaps more slowly, than mid-life patients from acute combined treatment (nortriptyline+interpersonal psychotherapy) of major depression. Given also the apparently higher relapse rate among the elderly, however, continuation treatment needs to be vigorous and closely monitored. The occurrence of severe life events prior to the index episode and the co-existence of an anxiety disorder both appear to prolong treatment response times, while chronic medical burden per se neither compromises response rates nor prolongs time to response. Self-rated perception of health improves with remission of depression in the elderly. As in mid-life patients, both antidepressant medication (nortriptyline) and interpersonal psychotherapy appear to possess chronic efficacy with respect to the prevention of recurrent episodes and prolongation of wellness. Finally, treatment of depression in the elderly results in improved quality of life, especially in domains of well being and coping. Particular challenges in the treatment of elderly patients are noncompliance and the prevention of suicide. The latter is closely linked to feelings of hopelessness, and these may be persistent in some patients.

Suicide in Elderly Depressed Patients: Is Active vs. Passive Suicidal Ideation a Clinically Valid Distinction?

The authors determined differential clinical correlates of active suicidal ideation vs. passive death wish in elderly patients with recurrent major depression. Measures of lifetime suicidal behavior and ratings of suicidal ideation, hopelessness, and depression determined "ideator" status. Active and Passive Ideators as well as Non-Ideators were then compared. Sixty percent of Active Ideators endorsed disgust or self-hatred items on the Beck Depression Inventory, compared with only 25% of Passive Ideators and 20% of Non-Ideators. However, these data challenge the clinical utility of distinguishing active and passive suicidal ideation among such patients because the two groups overall appear to be more alike than different, and ideator status (passive vs. active) may change during an episode. Clinicians should therefore not be less clinically vigilant if such patients' suicidal ideation is "only" passive.

Recovery from depression: risk or reality?

Depression is a serious condition associated with a high rate of recurrence in all populations of depressed patients. Research studies in the past have focused more on the criteria for onset of depressive disorder than on consistent criteria for outcome. However, the issue of concern to the patient is whether their depression is a lifelong condition or a condition from which they can reasonably expect to make a complete recovery. The issues surrounding recovery from depression are reviewed in the following article. The lifetime prognosis of depression is examined with reference to the Zürich follow-up study, and outcome criteria and the importance of assessing recovery in terms of quality of life as well as symptomatic improvement are considered. The relevance of clinical trial results to the clinical management of depression is also addressed.

Management of treatment resistance in the depressed geriatric patient

The treatment of depression in geriatric patients is challenging on all levels. Recognition, compliance, medical comorbidity, tolerance of drug regimens, and accessibility of the patient to therapy all represent major clinical problems. Treating depression in elderly, disabled patients requires patience, keen observation skills, and much flexibility. It is critical that these patients trust their physicians and have ready access if problematic side effects develop. In general, when treating patients with a history of failure to respond, the clinician should choose a medication with a tolerable side-effect profile, and persist with it as long as steady, slow gains are being made. Dosages should be maximized to clinical tolerance prior to considering switching agents or augmentation strategies. It is probably wiser to augment than switch if a partial response has been obtained. Particularly among the medically ill elderly, any "lost ground" may be very difficult to replace. All available psychosocial resources should be assessed and brought to bear productively in the treatment context. We are quite far from a full clinical understanding of "treatment resistance" in elderly depressive patients, but the eminent treatability of depression in elderly patients encourages creative exploration of treatment regimens. Rigorous, placebo-controlled studies of representative samples of elderly patients are needed to clarify the diverse interactions among the many pharmacologic agents available to treat resistant/refractory depression in the elderly.